Ischaemic stroke and TIA: acute care and secondary prevention

Image the brain urgently in everyone with suspected acute stroke before any specific treatment, ideally within 30 minutes of arrival. A non-contrast CT to exclude haemorrhage comes first, and thrombolysis should not wait for advanced CT or MR imaging.

Class I; level A (imaging); Class I; level B (timing)Section 2

Within 4.5 hours of onset, give intravenous alteplase to eligible patients; tenecteplase is a non-inferior alternative. Thrombolysis is also reasonable for people over 80 within 4.5 hours.

Alteplase Class I; level A; tenecteplase Class IIa; level B; over 80 Class IIa; level BSection 3.1

Offer mechanical thrombectomy within 6 hours for anterior circulation large-vessel occlusion (internal carotid or M1) with a pre-stroke modified Rankin score of 0–1, NIHSS of 6 or more and ASPECTS of 6 or more, and up to 24 hours in patients meeting the DAWN or DEFUSE 3 imaging criteria. If thrombolysis is indicated, start it first while arranging thrombectomy.

Class I; level ASection 3.2

Give aspirin within 24–48 hours of onset (24 hours after thrombolysis). For minor stroke or high-risk TIA not treated with thrombolysis, start aspirin plus clopidogrel within 24 hours for 21 days, then clopidogrel alone to 90 days.

Class I; level ASection 4.1; Section 4.2

For secondary prevention: blood pressure below 130/80 mmHg if tolerated; a high-intensity statin, adding ezetimibe to reach LDL-C below 1.8 mmol/L (70 mg/dL); and oral anticoagulation for atrial fibrillation.

BP Class I; level B; statin Class I; level A; anticoagulation Class I; level ASection 9.1; Section 9.2; Section 8

Provide early rehabilitation in an organised interdisciplinary stroke service, and formally assess daily activities, communication and mobility before discharge to plan the transition of care.

Class I; level A; discharge assessment Class I; level BSection 6

Use the NIHSS to grade stroke severity. A TIA is transient neurological dysfunction from focal brain, spinal cord or retinal ischaemia without acute infarction.

Class I; level BSections 1 and 2

Check blood glucose before thrombolysis. An ECG and blood tests (electrolytes, kidney function, blood count, coagulation) are recommended but must not delay treatment.

Glucose Class I; level B; other tests Class I; level CSection 2

For wake-up stroke or unknown onset, MRI showing a DWI–FLAIR mismatch, or a perfusion–core mismatch on CT or MR, can identify people who may still benefit from thrombolysis.

Class IIa; level BSection 2; Section 3.1

Record a 12-lead ECG in every ischaemic stroke to look for atrial fibrillation; check the pulse routinely in people over 65 and do an ECG if it is abnormal. In cryptogenic stroke, monitor the heart rhythm for at least 24 hours.

Class I; level B; pulse check Class I; level A; monitoring Class IIa; level BSection 7

Arrange a chest X-ray and transthoracic echocardiography to look for structural heart disease.

Class I; level CSection 7

Screen everyone for diabetes and pre-diabetes after stroke (HbA1c, fasting glucose or an oral glucose tolerance test).

Class IIa; level BSection 7; Section 9.3

Screen swallowing before the person eats, drinks or takes oral medicines; screening can be done by a speech and language therapist or other trained staff.

Class I; level CSection 6

Before thrombolysis, bring blood pressure below 185/110 mmHg, and keep it below 180/105 mmHg during and for 24 hours after treatment.

Class I; level BSection 3.1

If no reperfusion treatment is given and blood pressure is below 220/120 mmHg, starting antihypertensives in the first 48–72 hours does not prevent death or disability. Above 220/120, lowering by about 15% in the first 24 hours may be reasonable; lower it early if there is an acute coronary event, acute heart failure or aortic dissection.

Class III; level A; comorbidities Class I; level CSection 9.1

Give oxygen only to keep saturation above 94%, not to non-hypoxic patients. Correct glucose below 3.3 mmol/L (60 mg/dL) and keep raised glucose at 7.8–10.0 mmol/L (140–180 mg/dL) while avoiding hypoglycaemia.

Oxygen Class I; level C / not if non-hypoxic Class III; level B; glucose Class IIa; level CSection 6; Section 9.3

Start enteral nutrition within 7 days. With dysphagia, use a nasogastric tube early and consider a gastrostomy if dysphagia is expected to last more than 2–3 weeks; give supplements to people who are malnourished or at risk.

Class I; level B; tube feeding Class IIa; level C; supplements Class IIa; level BSection 6

For people with limited mobility, use intermittent pneumatic compression to prevent DVT; do not use elastic compression stockings routinely.

Class I; level B; stockings Class III; level BSection 6

With atrial fibrillation, anticoagulate with warfarin (INR 2–3) or a newer oral anticoagulant, starting 2–14 days after onset depending on stroke severity and bleeding risk (delay to 14 days if the haemorrhage risk is high). If anticoagulation is declined, give aspirin.

Class I; level A; aspirin if declined Class I; level BSection 8

With a recent stroke or TIA (within 6 months) and 70–99% ipsilateral carotid stenosis, offer endarterectomy or stenting if the risk of perioperative death or stroke is below 6%; the same applies to 50–69% stenosis, choosing the procedure to suit the patient. Do not revascularise stenosis below 50%.

70–99% Class I; level A; 50–69% Class I; level B; below 50% Class III; level ASection 8

Lifestyle: stop smoking with medication and behavioural support and avoid passive smoke; limit alcohol to 2 standard units a day for men and 1 for women; take regular moderate exercise if able; lose weight if overweight; eat more whole grains, legumes, fruit and vegetables with less salt and saturated fat.

Smoking Class I; level A; alcohol Class IIa; level B; exercise and weight Class I; level BSection 9.4

For people with diabetes, set individual glucose targets and avoid hypoglycaemia; GLP-1 receptor agonists and SGLT2 inhibitors are reasonable choices. Pioglitazone may help people with insulin resistance but no diabetes.

Class IIa; level BSection 9.3

Do not give anti-seizure drugs prophylactically. If epilepsy develops after stroke, lamotrigine or levetiracetam may be preferable to carbamazepine or valproate.

Class III; level C; drug choice Class IIb; level BSection 6

Age alone should not exclude thrombolysis: trials largely excluded people over 80, but similar benefit is seen. People with multiple comorbidities, general weakness or pre-stroke disability may also benefit.

Over 80 Class IIa; level B; comorbidity or disability Class IIb; level BSection 3.1

When carotid revascularisation is indicated in someone aged 70 or over, endarterectomy is preferred to stenting.

Class IIa; level BSection 8

For malignant middle cerebral artery infarction with deterioration within 48 hours, decompressive surgery is reasonable up to age 60 but only “may be considered” above 60.

Class IIa; level A up to 60; Class IIb; level B over 60Section 6

Avoid high-dose, very early mobilisation within 24 hours, and match the intensity of rehabilitation to expected benefit and tolerance.

Class III; level B; intensity Class I; level BSection 6

Avoid routine urinary catheters (infection risk) and prophylactic antibiotics; good oral hygiene may reduce pneumonia.

Class III; level C; antibiotics Class III; level B; oral care Class IIb; level BSection 6

Alteplase 0.9 mg/kg (maximum 90 mg): 10% as a bolus over 1 minute and the rest over 60 minutes. Tenecteplase 0.25 mg/kg (maximum 25 mg) as a single bolus; the higher 0.4 mg/kg dose is harmful with NIHSS above 6.

Alteplase Class I; level A; tenecteplase Class IIa; level BSection 3.1

Dual antiplatelet therapy for minor stroke or high-risk TIA: aspirin 100 mg daily plus clopidogrel 300 mg loading then 75 mg daily for 21 days, then clopidogrel alone to 90 days. In carriers of CYP2C19 loss-of-function alleles, use ticagrelor (180 mg loading, then 90 mg twice daily) with aspirin for 21 days, then ticagrelor alone to 90 days.

Class I; level ASection 4.2

Long-term single antiplatelet: aspirin 50–325 mg a day or clopidogrel 75 mg a day; cilostazol is an alternative for people at high bleeding risk.

Class I; level A; cilostazol Class IIb; level BSection 4.1

Transfer people with a large infarct to intensive care and watch for brain oedema. Cerebellar infarction compressing the brainstem needs suboccipital decompression, and obstructive hydrocephalus a ventriculostomy.

Class I; level C; decompression Class I; level BSection 6

Anyone with residual deficits should have a functional assessment by a clinician with rehabilitation expertise.

Class I; level CSection 6

Cardiac abnormalities found on screening should be managed with specialist input.

Class I; level BSection 7

Every delay worsens the outcome: do not postpone thrombolysis to see whether symptoms resolve.

Class III; level CSection 3.1

Do not thrombolyse after any low-molecular-weight heparin in the previous 24 hours, and do not give intravenous aspirin within 90 minutes of starting thrombolysis.

Class III; level BSection 3.1

Symptomatic haemorrhagic transformation: stop antiplatelets and anticoagulants.

Class I; level CSection 6

Do not use corticosteroids for brain oedema or raised intracranial pressure after infarction.

Class III; level ASection 6

The 2023 update adds 136 new and 15 revised recommendations, including tenecteplase as an alternative to alteplase, thrombectomy for large-core infarcts and basilar artery occlusion, and CYP2C19-guided ticagrelor-based dual antiplatelet therapy.

Highlights; Abstract